Permanent Maryland bridge

Maryland bridge

Maryland bridge is a common prosthesis for patients that are too young or don’t have the bone for dental implants. Often they are done when a person is missing a lateral incisor. The lateral incisor is the small tooth right next to the center one. This is genetic, very common and it runs in families, so blame mom and dad!!

What are the marlyand bridge options?

The are several variations of the maryland bridge out there. Materials that we use are either metal, porcelain, or composite. The porcelain we use is usually zirconia or pure emax, both of these have pluses and minuses. I would recommend going with whatever your dentist recommends, provided they can show you before and after pictures of their own work that you find acceptable. My opinion on technique and material questions is that the best material in the world isn’t the best in the hands of someone that hasn’t used it before or doesn’t like it.

There are only three major design decisions to make and you should ask your dentist what they prefer.

The questions to ask are

One wing or two? We have had several one wings rotate so there does exist some complications with the single wing. These were done shortly after braces when the teeth were still settling and we believe that had something to do with it.

Will you use metal or ceramic for the substructure support?

Will the cosmetic part be made out of composite or ceramic?

Porcelain fuse to metal Maryland bridge (PFM Maryland bridges)

This is what the vast majority of dentists use for their Maryland bridges. The material and technique is time tested and both labs and dentists are all familiar with it.

Emax maryland bridges

These are becoming more common but require more thickness to be strong enough. The ones that can be found online are in our opinion too bulky and unaesthetic.

Zirconia maryland bridges

These can be very good but one must worry about how well you are bonding to the tooth structure with zirconia. Some are creating methods to allow for porcelain to bond to the tooth and still utilizing the strength of the zirconia. This is accomplished through either holes in the zirconia that the lab fills with porcelain or porcelain circumferentially around the zirconia.

Composite Maryland bridge

A composite Maryland bridge is not very useful for most people. I only use if someone can not afford anything but the cheapest possible option. Even then I will only use it on someone that is very old and will likely not need it much longer. Usually it is a patient that is thinking of just leaving the space and doesn’t care very much. This patient often makes one of the funnier jokes I hear from very old patients, ” Honey, at my age I don’t even buy green bananas.”

If you are reading about Maryland bridges you are not going to be getting something this cheap.

Bad photo for a composite Maryland bridge, not that a good photo would do it any justice. This is not a high esthetic option.

Issues that make a maryland bridge more challenging

There are several things about you that can make a maryland bridge hard to do well.

First off is how hard are you on your teeth? Grinders, clenchers, people that have hard diets will pop these off on a regular basis. No one will be happy.

Where is your smile line? That means how much gum tissue do you show when you smile? If the answer is none, then the esthetics of where the tooth needs to look like it’s coming out of the gums is not that important. If you have a gummy smile it is going to be a challenge to get it to look natural. The best method will include some type of temporary to train the gum tissue.

The final issue is the amount of tissue and bone you have to work with. If there isn’t much tissue or bone then the dentist can’t make it look like it’s coming out of the gums naturally. Many people with little bone will have an indention in that area and it will never look natural without doing some sort of gum graft before the maryland bridge is made. The other issue with these indented areas is the tooth always looks darker as the lip casts a shadow on it because it sinks in more in that area.

Marlyand bridge before and after pictures

This is an example of two Maryland bridges that we did on a young girl. We are using a modified version of the traditional Maryland bridge in which we use only 1 wing. This method allows to only reduce the back side of one tooth instead of two. In this particular case these are her final restorations that she will have for as long as she can keep them.

Laser gum treatment for maryland bridges

It makes a big esthetic difference if you can train or treat the tissue before delivery of final maryland bridge. Ideally the final result looks like the tooth is coming out of the gums, not sitting on top of the gums. If you have very little bone and/or tissue width this may not be possible or be very challenging anyway.

Maryland bridge information for dentist and lab

Connecting the maryland bridge to a cuspid and incisor is more likely to cause adhesion failure at the incisor. This adhesion failure can lead to decay if not detected. Best methd for the one wing is to connect it to the canine. Keep the prep in enamel with a Yamahita design. Use non-precious metal, like Rexillium III, sandblast it and bond with MDP containing material like Panavia. Keep the metal supraginigval due to metal sensitivity. Do not let the lab electrolytically etch the non-precious metal, you can just blast it with aluminum oxide before bonding it. Don’t wash off the residual sand, simply apply your MDP containing resin.

Panavia 21 to porcelain fused to metal Maryland bridge

Maryland bridge to base metal

Sandblast 2-3 seconds per cm2. (30-50 micron alumina)

Air dry

Mix A and B for 35 seconds

Place A and B on tooth for 60 seconds

Air dry

1 full turn and mix cement 20-30 seconds

Seat restoration with finger pressure for 60 seconds

Place Oxyguard II for 3 minutes

Clean up excess with scaler or explorer

What is a Yamashita prep design?

Yamashita adhesion bridges use intra-enamel grooves on mesial and distal. I heard about it on this dentaltown thread. In that thread it said Botelho et al. has a study showing the Yamashita prep design, but I looked at the study and found that is not the case. Here is what the study says, “As this study was retrospective, it was not possible to describe the biomechanical variables of the prostheses, such as thickness of retainer and use of grooves, pins, or cingulum rests, and these variables were therefore not controlled.” Frankly, I can not find a great description or picture of it anywhere.

Despite that the prep design that I use has 2 retention spots and 1 retention groove. It forms a smiley face and my lab said it makes her happy so I like it.

Smiley face maryland bridge prep design for added retention. The benefits of this design are debatable and as I look at this I feel the shape of the retention grooves should be inverted.

What is the Maryland bridge dental code?

The dental code for a Maryland bridge is actually going to be 2 or 3 dental codes depending on if we use 2 or 1 wing. The wing or retainer is dental code D6545 for metal and D6548 for porcelain, so think emax or zirconia. The pontic tooth is dental code D6242 for noble metal and D6245 for porcelain.